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Acceptability of Formula-Feeding to Prevent HIV Postnatal Transmission, Abidjan, Côte d'Ivoire: ANRS 1201/1202 Ditrame Plus Study
Global Health Sciences Literature Digest
Published February 20, 2007
Journal Article

Leroy V, Sakarovitch C, Viho I, Becquet R, Ekouevi DK, Bequet L, Rouet F, Dabis F, Timite-Konan M; the ANRS 1201/1202 Ditrame Plus Study Group. Acceptability of Formula-Feeding to Prevent HIV Postnatal Transmission, Abidjan, Côte d'Ivoire: ANRS 1201/1202 Ditrame Plus Study. J Acquir Immune Defic Syndr. 2007 Jan 1;44(1):77-86.


To describe the acceptability of formula-feeding alternatives to reduce postnatal HIV transmission to mothers in Abidjan, Côte d'Ivoire.

Study Design

This was a non-randomized prospective cohort study.


This study took place in two of the most densely populated districts of Abidjan, Côte d'Ivoire. Yopougon University Hospital and two community-run clinics were selected as study sites. HIV seroprevalence estimates from pregnant women were consistently 11% to 12% at these sites during the study period.


From March 6, 2001 through March 6, 2003, all pregnant women attending the two prenatal clinics were eligible to enroll in the study if: 1) they were pregnant and presenting at <36 weeks of gestation; 2) were 18 years or older, testing positive for HIV (HIV-1 or dually reactive HIV-1+2) with a hemoglobin result >7g/dL; and 3) lived within the city limits of Abidjan. In total, 643 women were enrolled in the study.


At inclusion, study participants were individually counseled about the advantages of breast milk and the risk of postnatal transmission. Two alternatives to prolonged breastfeeding were proposed: exclusive formula feeding from birth, or exclusive breastfeeding with early cessation within the fourth month. During subsequent weekly prenatal visits until delivery, the advantages, disadvantages, possible stigmatization, and potential risk to infant health related to both alternatives were discussed with mothers. Formula feeding from birth was proposed free of charge up to nine months, and facilitated by the use of a single oral dose of cabergoline for inhibiting lactation. The second proposed alternative consisted of exclusive breastfeeding with the aim of weaning after a short period (not exceeding two weeks) and obtaining complete cessation of breastfeeding between three and four months of age. All participants could express their feeding choices until birth, and the staff supported their choices and counseled them accordingly. The following materials were provided free of charge to women willing to refrain from breastfeeding: bottles, teats, bottles brush, a pan to sterilize, a thermos in which to keep clean water, and a controlled distribution of local powdered infant formula (one box at each follow-up visit) until nine months of age. Participants were also trained to correctly prepare and store bottles, and to adequately feed their children with clean hands and clean utensils. Pregnant women were observed weekly until delivery and mother-infant pairs were seen 48 hours after birth, weekly until six weeks of age, monthly until nine months of age, and every three months until the second birthday. At each scheduled visit, clinical, nutritional, psychosocial, and biological follow-up of both mothers and infants was proposed. Nutritionists were available to individually counsel women about infant-feeding practices whenever needed. Blood samples were collected at Day 2 and Week 4, 6, 12, and then every three months until 18 months or until two months after complete cessation of breastfeeding if the child was ever breastfed. Serology was performed at 18 months in all children.

Primary Outcomes

Various determinants of formula-feeding acceptability were measured.


Of the 643 women enrolled in the study, 44 were lost to follow-up and 19 were infected with HIV-2 only and were thus not eligible for the study. Of the remaining 580 pregnant women who delivered, 309 (53%) had expressed their willingness to formula-feed, 256 (44%) had planned to breastfeed, and 5 (3%) did not express any choice before delivery. The prenatal acceptability of formula feeding was estimated to be 53% (95% CI: 49% to 57%). Using multivariate adjusted analysis, socio-demographic variables significantly associated with the maternal refusal of the formula-feeding option were: living with her partner, being Muslim, having a low educational level, and not having shared her HIV status with someone else. Of the 309 mothers who chose to formula feed, one was lost to follow-up after birth, and 13 could not implement any infant feeding due to the deaths of their children. At Day 2, 267 (91%) of the remaining 295 women who had chosen formula feeding before birth had actually initiated this practice after birth in agreement with their prenatal choices, and 28 (9%) changed their minds and decided to breastfeed from birth. At Day 2, among those 267 who formula-fed consistently with their prenatal choice, 93% were exclusively formula feeding while 7% were using mixed breast and formula feeding. During the first year, 46 (15.6%) of the women formula feeding failed to maintain exclusive formula feeding and breastfed at least one time, with 85% of these failures occurring in the neonatal period. Of these 46 women, 19 (41%) used both breast and formula feeding at Day 2 for the following reasons: forgot their formula-feeding material at delivery in maternity (n=6), were pressured by family (n=5), baby crying (n=4), followed midwife's advice (n=3) and unknown (n=1). Beyond the early neonatal period, the reasons for switching to breastfeeding were as follows: probable family pressure not admitted (n=12), family pressure admitted (n=10), logistic constraints (n=2), desire to breastfeed (n=2). Using multivariate analysis, the only variable explaining the failure of formula feeding was having a low-birth-weight newborn [AOR 2.4, 95% CI: 1.1, 5.4].


In this study setting, with general access to clean water, structured antenatal counseling, and sustained provision of free formula, slightly over half of HIV-infected women chose to artificially feed their newborn infants, and low mixed-feeding rates were observed. This social acceptability must be balanced with mother-child long-term health outcomes to guide safe recommendations on infant feeding among HIV-infected women in African urban settings.

Quality Rating

Using the Newcastle-Ottawa grading system, this study received a good rating. The selection process allowed for a representative sample of HIV-infected pregnant women to be included in the study, mothers were observed for two years following birth with only a few women lost to follow-up, and outcomes were obtained through self-reporting and confirmed by physical examination. However, a limitation to this study is the fact that it can only be generalized to specific settings: urban sites with available clean water sources, programs able to provide alternative infant-feeding options (in this case, infant-feeding formula and supplies), and programs able to provide clinical counseling and support.

In Context

The authors showed that the uptake of formula feeding was high in the study population known for usually practicing prolonged breastfeeding. (1,2) Almost all HIV-infected women expressed their infant-feeding choice before delivery, and the formula-feeding option was better accepted than anticipated: slightly over half of HIV-infected women chose it in the prenatal period, whereas the baseline hypothesis was estimated around 20%.(2) Similar results were found in East Africa, where Magoni et al (3) reported a 40% neonatal acceptance rate of formula-feeding offered free of charge to 306 mothers enrolled in a PMTCT program in an urban hospital center in Kampala, Uganda, and failure to maintain exclusive formula feeding was reported in 11% of the women up to six months of age.

Programmatic Implications

In settings where programs are able to provide formula and equipment to HIV-infected mothers, and where drinking water supplies are safe, providing mothers with alternatives to prolonged breastfeeding could provide an option to help decrease PMTCT infections in resource-poor settings.


  1. Leroy V, Karon JM, Alioum A, et al. Twenty-four month efficacy of a maternal short-course zidovudine regimen to prevent mother-to child transmission of HIV-1 in West Africa. AIDS 2002;16:631-641.
  2. Becquet R, Castetbon K, Viho I, et al. Infant feeding practices before implementing alternatives to prolonged breastfeeding to reduce HIV transmission through breastmilk in Abidjan, Côte d'Ivoire. J Trop Pediatr. 2005;51:351-355.
  3. Magoni M, Bassani L, Okong P, et al. Mode of infant feeding and HIV infection in children in a program for prevention of mother-to-child transmission in Uganda. AIDS. 2005;19:433-437.